Author + information
- Received September 12, 2018
- Revision received September 24, 2018
- Accepted October 4, 2018
- Published online March 18, 2019.
- Shaojie Chen, MD, PhD,
- Boris Schmidt, MD, FHRS,
- Stefano Bordignon, MD,
- Fabrizio Bologna, MD,
- Edelgard Lindhoff-Last, MD and
- K.R. Julian Chun, MD∗ ()
- Cardioangiologisches Centrum Bethanien Frankfurt am Main, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Frankfurt am Main, Germany
- ↵∗Address for correspondence:
Dr. K.R. Julian Chun, Cardioangiologisches Centrum Bethanien Frankfurt am Main, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Wilhelm-Epstein Straße 4, 60431 Frankfurt am Main, Germany.
A 55-year-old male patient (CHA2DS2-VASc [Congestive Heart Failure, Hypertension, Age ≥75 Years, Diabetes Mellitus, Prior Stroke or Transient Ischemic Attack or Thromboembolism, Vascular Disease, Age 65 to 74 Years, Sex]score: 0, HASBLED [Hypertension, Abnormal Renal and Liver Function, Stroke, Bleeding, Labile International Normalized Ratio, Elderly, Drugs or Alcohol] score: 0) was scheduled for a third atrial fibrillation ablation procedure within 3 years due to symptomatic, drug refractory recurrence of persistent atrial fibrillation despite durable pulmonary vein isolation. Before all ablation procedures, left atrial (LA) thrombus was ruled out by transesophageal echocardiography. During the third procedure, all pulmonary veins proved durable isolation, therefore additional linear ablations were deployed. After bidirectional-block of the LA anterior line, roof line, and left isthmus line, the left atrial appendage (LAA) was consequently electrically isolated. The patient was discharged on continued oral anticoagulation therapy (rivaroxaban 20 mg once daily). During 4 weeks of follow-up, after the last ablation-procedure, the patient remained in sinus rhythm. The rivaroxaban plasma-level proved to be within therapeutic range: 29 ng/ml (12 to 137 ng/ml). However, the transesophageal echocardiography revealed a novel thrombus formation within the distal LAA along with a reduced LAA flow (Figures 1A and 1B). Electrophysiological testing using a circular diagnostic catheter (15-mm LASSO; Biosense Webster) positioned in the proximal LAA proved durable electrical isolation (Figures 1C and 1D). Consequently, we took the decision to proceed with left atrial appendage occlusion (LAAO).
Considering that a Watchman device (Boston Scientific, Natick, Massachusetts) has to be placed deeper in the LAA and might dislodge the thrombus, we selected the 2-component design (lobe-disc), 31-mm LAA device (Amulet, Abbott, Chicago, Illinois) for LAAO. Figures 2A to 2D show the process of LAAO. After LAAO, the patient received dual antiplatelet therapy (aspirin 100 mg/day + clopidogrel 75 mg/day) for 6 weeks. After 6 weeks, transesophageal echocardiography revealed no LA- or device-related thrombus formation and low-dose dabigatran 110 mg was initiated. After 6-month follow-up, the patient remained in sinus rhythm along with no clinical signs of stroke or bleeding complications.
This report points toward: 1) the important relationship between LAA isolation and thrombus formation; 2) increased stroke risk in LAA isolation despite of anticoagulation; and 3) the role of LAAO after LAA thrombus formation in selected patients.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received September 12, 2018.
- Revision received September 24, 2018.
- Accepted October 4, 2018.
- 2019 American College of Cardiology Foundation